Frances R. Batzer

Serial β-Subunit Human Chorionic Gonadotropin Doubling Time as a Prognosticator of Pregnancy Outcome in an Infertile Population*

Prospective evaluation through the use of radioimmunoassay of the beta-subunit of human chorionic gonadotropin (beta-hCG) in blood samples obtained during the first 30 days of gestation was performed on an infertile population at high risk for pregnancy loss. Four hundred and fourteen samples in 281 pregnancies were analyzed. On the basis of single, random beta-hCG samples in asymptomatic patients, 77% of successful pregnancies and 59% of abortions were correctly identified. On the basis of beta-hCG doubling time (mean 2.2 days +/- 1.0 [2 SD]) computed from serial sampling, again in asymptomatic patients, 88% of successful pregnancies and 76% of abortions were correctly identified. beta-hCG doubling time appears to provide a reliable method of evaluating early pregnancy prognosis with significantly greater ability to identify problem pregnancies within the first 30 days of gestation than does single random hCG values.

Paternal mononuclear cell immunization therapy for repeated miscarriage: predictive variables for pregnancy success.

ABSTRACT: Pregnancy outcomes for 125 women with unexplained recurrent abortion conceiving after immunologic testing for possible paternal leukocyte immunization were analyzed. Pregnancy success was related to the number of previous miscarriages (relative risk 0.36 for each additional miscarriage after 3), a history of a late pregnancy loss (relative risk 0.18), any other relevant treated or untreatable diagnosis (relative risk 0.27), immunization with paternal mononuclear cells (relative risk 5.6), and time in weeks from test date to LMP of the next pregnancy (relative risk 0.93 for each additional week). The significant difference in pregnancy outcomes between women given a single immunization and nonimmunized women reflected a larger difference between those in each group conceiving within 12 weeks of initiating tests for inclusion in the treatment program. The latter observation suggests that any effect from a single immunization in prevention of recurrent miscarriage is of relatively short duration.

Landmarks during the first forty-two days of gestation demonstrated by the β-subunit of human chorionic gonadotropin and ultrasound

Prospective pregnancy evaluation through the combined use of a radioimmunoassay (RIA) for the beta-subunit of human chorionic gonadotropin (beta-hCG) and ultrasound during the first 42 days of gestation after ovulation was performed on a population asymptomatic for first-trimester spontaneous abortion. One hundred forty-six ultrasonic observations in 98 pregnancies were made with simultaneous beta-hCG RIA performed in 80 patients. The following landmarks of normal gestational growth were identified: (1) Before 26 days, beta-HCG RIA permits definitive diagnosis of growing trophoblastic tissue, and serial samples allow doubling time computation for prognosis while ultrasound shows a nonspecific increasing decidual response within the uterus; (2) between 26 and 36 days after ovulation, serial beta-hCG samples continue to give doubling time results while ultrasonic demonstration of a gestational sac is normally seen by 28 days after ovulation; (3) the lack of fetal heart motion by 42 days after ovulation or within a gestational sac with a mean diameter of greater than 30 mm was prognostic of abortion; (4) the absence of a gestational sac by 28 days after ovulation or with a beta-hCG RIA greater than 1,000 ng/ml is suggestive of an ectopic pregnancy until proved otherwise.

Sex selection by sperm separation and insemination

The Ericsson albumin filtration technique was used to collect a fraction rich in Y sperm for selective insemination in couples desiring a male infant. Of 35 conceptions in which sex was known at delivery or spontaneous abortion, there were 28 males (80%). Twelve pregnancies were achieved after separation of sperm in a Sephadex gel filtration system designed to allow for collection of a fraction enriched in X sperm. Seven pregnancies have resulted in females, two in males, and one in twins of each sex. One patient aborted, and one is still pregnant. While selection for either sex can be done electively, on the basis of sociologic preference, female selection has, as an additional indication, avoidance of male offspring to carriers of sex-linked diseases.

Outcome in 242 in vitro fertilization-embryo replacement or gamete intrafallopian transfer-induced pregnancies

Two centers combined data on 152 in vitro fertilization embryo replacement and 90 gamete intrafallopian transfer generated pregnancies. The outcomes of the pregnancies with respect to abortion, ectopic gestation, and multiple gestation were evaluated independently by method and by center. Only with multiple gestation by center was a difference seen. Variables examined included estradiol levels, luteal phase support, maternal age, and prior reproductive history, and the number of eggs or embryos replaced.

Genetic offspring in patients with vaginal agenesis: Specific medical and legal issues

OBJECTIVE There are new options for genetic offspring in patients with vaginal agenesis (Mayer-Rokitansky-Küster-Hauser syndrome). The reported world experience to date with genetic offspring of patients with vaginal agenesis consists of five pregnancies (including two reported here and two frozen embryos). The specifics of these cases are presented for discussion. STUDY DESIGN We present a retrospective description of two women with vaginal agenesis and their matched gestational carriers with positive outcome of two live births. Care was delivered in a private in vitro fertilization and gamete intrafallopian transfer program. RESULTS In vitro fertilization of oocytes gathered from the genetic mother with vaginal agenesis and sperm from the genetic father were transferred to a gestational carrier. Two live births and one blighted ovum pregnancy resulted. CONCLUSION Until recently, treatment for patients with vaginal agenesis (Mayer-Rokitansky-Küster-Hauser syndrome) has centered on the creation of a functional vagina. The technology of in vitro fertilization and embryo transfer, allowing for collection of oocytes from the genetic mother, fertilization by the genetic father, and placement into a gestational carrier, enables a woman without a uterus to have her own genetic children. The specific medical and legal issues involved in facilitating genetic offspring in these instances must be considered; these include the initial matching of the genetic parents with the gestational carrier, cycle synchronization for in vitro fertilization and embryo transfer, anatomic difficulties of oocyte retrieval, birth certificate documentation, and the current legal status of a gestational carrier.

Predicting success of gamete intrafallopian transfer.

OBJECTIVES To examine seminal parameters predictive for success in a cycle of GIFT and to construct an algorithm using pertinent seminal data as well as easily obtained historical data to predict pregnancy and viable pregnancy rates. DESIGN A retrospective study of 544 cycles in 376 couples. SETTING A private IVF-ET and GIFT center. PATIENTS Couples in a GIFT program with a mean of 53.6 months of infertility who had failed to conceive with other therapies. INTERVENTIONS Gamete intrafallopian transfer. MAIN OUTCOME MEASURES Pregnancy as a function of laboratory historical data with emphasis on seminal parameters. RESULTS Motility was the only seminal parameter that was predictive. Success was correlated with the number of oocytes returned and inversely related to female age. An algorithm to predict pregnancy in a GIFT cycle as well as viable pregnancy was constructed. CONCLUSIONS Motility is the only seminal parameter predictive for success in a GIFT cycle. An easily programmable algorithm can be constructed to help patient and physician decide on the appropriateness of GIFT for each couple.

Leuprolide acetate-prepared in vitro fertilization-gamete intrafallopian transfer cycles: efficacy versus controls and cost analysis *

OBJECTIVE To evaluate the effect of gonadotropin-releasing hormone agonist (GnRH-a) when given through stimulation with gonadotropins versus stopping it as stimulation was initiated versus a control group unprepared in this manner. Also, to construct a cost analysis for this type of therapy in an in vitro fertilization-gamete intrafallopian transfer program (IVF-GIFT). DESIGN Prospective, consecutive, randomized, with a control group. SETTING An out-patient IVF-GIFT program. PATIENTS One hundred new patients entering an IVF-GIFT program. INTERVENTIONS In vitro fertilization or GIFT cycles with or without preparation (pituitary suppression) by GnRH-a administration in which suppression was continued or halted as gonadotropins were begun. MAIN OUTCOME MEASURES Cancellation rates, ampules, and days of gonadotropin use, costs, estradiol (E2) level, egg numbers and quality, and pregnancy rates. RESULTS Stopping GnRH-a (leuprolide acetate) therapy as stimulation was begun did not lessen the suppressive effect in reduction of spontaneous luteinizing hormone surge as seen with continued use of agonist. In contrast, the control group had a 30.3% cancellation rate before ovum retrieval. The E2 and egg data among the groups were similar, but as expected, agonist use led to the need for more and longer duration of gonadotropin stimulation. Pregnancy rates were not different by group. Costs were approximately even by the third initiated cycle.

Insemination data on men with varicoceles

Objective To determine possible benefits of sperm processing and intrauterine insemination (IUI) for a group of men with a varicocele history who had not achieved a pregnancy by natural coitus (mean duration of infertility 42.2months). Design A retrospective study including infertile men with varicoceles who were classified by their semen analyses and sperm penetration assays (SPAs). Setting Private practice of infertility. Patients Seventy-one infertile couples. The husbands had a varicocele history and were grouped into four clinical categories (14 untreated, 5 medical treatment, 34 varicocelectomies, and 18 varicocelectomies plus medical treatment). The wives were studied or treated before IUI. Interventions Varicocelectomies were performed on the males when indicated. Female studies included laparoscopies as indicated intrauterine insemination with Tomcat catheter (Sherwood Medical, St. Louis, MO) was performed in all cases. Main Outcome Measures Overall pregnancy rates (PRs) and fecundity rates with sperm processing and IUI. Results Six pregnancies occurred with 66cycles of sperm processing and IUI among 28 men with normal SPAs (PR 21%, fecundity rate=0.09). In contrast, there were no pregnancies with 121cycles among 43 varicocele patients with abnormal SPA results or with low values for all three semen parameters. Conclusions Sperm processing and IUI may be beneficial for selected patients with varicoceles who had not achieved a pregnancy by coitus.

PREGNANCY DESPITE CONTINUED ELEVATION OF PROLACTIN LEVELS WHILE ON BROMERGOCRYPTINE

A case of long standing secondary amenorrhea with hyperprolactinemia and pregnancy success despite inability to normalize prolactin levels with high doses of bromergocryptine is presented.